Learning Curve and Case Selection in Laparoscopic Colorectal Surgery

Mišković, Danilo; Ni, Melody; Wyles, Susannah M.; Tekkis, Paris; Hanna, George B.

doi:10.1097/dcr.0b013e31826ab4dd

Cited by 192 publications

(61 citation statements)

References 54 publications

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“…44,45 In addition, there is the further learning curve associated with techniques inherent to laparoscopic and robotic operations. 46,47 Kluger et al 48 recently described the importance of development of proper skills in laparoscopic techniques to achieve acceptable perioperative outcomes. Although it is likely that the learning curve for these technically demanding operations is a major contributor to the current low use of MIS HPB surgery, as current trainees gain greater exposure to these techniques the adoption of MIS into complex abdominal operations will likely increase.…”

Section: Discussionmentioning

confidence: 99%

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the nationwide inpatient sample

Ejaz¹,

Sachs²,

He³

et al. 2014

Surgery

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Background The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort. Methods We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups. Results A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001). Conclusion During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.

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Section: Discussionmentioning

confidence: 99%

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the nationwide inpatient sample

Ejaz¹,

Sachs²,

He³

et al. 2014

Surgery

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“…This might be attributed to the higher technical difficulty and learning curve associated with the laparoscopic procedure. 32–34 …”

Section: Discussionmentioning

confidence: 99%

Is Minimally Invasive Colon Resection Better Than Traditional Approaches?

et al. 2014

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IMPORTANCE Minimally invasive colectomies are increasingly popular options for colon resection. OBJECTIVE To compare the perioperative outcomes and costs of robot-assisted colectomy (RC), laparoscopic colectomy (LC), and open colectomy (OC). DESIGN, SETTING, AND PARTICIPANTS The US Nationwide Inpatient Sample database was used to examine outcomes and costs before and after propensity score matching across the 3 surgical approaches. This study involved a sample of US hospital discharges from 2008 to 2010 and all patients 21 years of age or older who underwent elective colectomy. MAIN OUTCOMES AND MEASURES In-hospital mortality, complications, ostomy rates, conversion to open procedure, length of stay, discharge disposition, and cost. RESULTS Of the 244 129 colectomies performed during the study period, 126 284 (51.7%) were OCs, 116 261 (47.6%) were LCs, and 1584 (0.6%) were RCs. In comparison with OC, LC was associated with a lower mortality rate (0.4%vs 2.0%), lower complication rate (19.8%vs 33.2%), lower ostomy rate (3.5 vs 13.0%), shorter median length of stay (4 vs 6 days), a higher routine discharge rate (86.1%vs 68.4%), and lower overall cost than OC ($11 742 vs $13 666) (all P < .05). Comparison between RC and LC showed no significant differences with respect to in-hospital mortality (0.0%vs 0.7%), complication rates (14.7%vs 18.5%), ostomy rates (3.0% vs 5.1%), conversions to open procedure (5.7%vs 9.9%), and routine discharge rates (88.7%vs 88.5%) (all P > .05). However, RC incurred a higher overall hospitalization cost than LC ($14 847 vs $11 966, P < .001). CONCLUSIONS AND RELEVANCE In this nationwide comparison of minimally invasive approaches for colon resection, LC demonstrated favorable clinical outcomes and lower cost than OC. Robot-assisted colectomy was equivalent in most clinical outcomes to LC but incurred a higher cost.

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“…Presumably these correct results are due first to the surgical technique used (minimally invasive surgery), which in colorectal pathology has turned out to have fewer complications during the immediate postoperative period compared to open surgery [21, 22], and the wide-ranging experience of the surgical team [23]. Moreover, they are also due to the careful selection of patients with a series-based determination of inflammatory parameters in blood during the first few postoperative days that seeks to predict early possible septic complications [24, 25].…”

Section: Discussionmentioning

confidence: 99%

Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery

et al. 2017

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Background: To audit the safety of the early hospital discharge care model offered by a Hospital-at-home (HAH) unit during early postoperative follow-up of these patients, and to determine whether this care model is more efficient compared to the traditional care model. Methods: A prospective study of 50 patients included consecutively for 1 year in an early discharge programme after laparoscopic colorectal surgery was performed. As of day 3 after surgery, if the patient met the relevant inclusion criteria they were transferred to the HAH unit. The domiciliary protocol consists of daily clinical follow-up and a series of analytical controls with the purpose of early detection of postoperative complications. If the clinical course was favourable on day 7 after the postoperative period the patient was discharged. Results: A total of 66% were males, and the mean age was 60.6 years. The surgical procedure most commonly performed was sigmoidectomy. The mean stay was 5.5 days. There were no deaths during follow-up. The average estimated cost per day of stay in a HAH system was EUR 174.29 whilst the same average cost on a surgery ward stood at EUR 1,032.42. Conclusions: For patients undergoing major colorectal surgery with minimally invasive surgical technique, an early hospital discharge care programme by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

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Learning Curve and Case Selection in Laparoscopic Colorectal Surgery

Abstract: This multicenter database suggests a length of the learning curve of 88 to 152 cases. The use of the suggested framework may prevent high conversion and complication rates during the learning curve.

Cited by 192 publications

References 54 publications

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the nationwide inpatient sample

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the nationwide inpatient sample

Is Minimally Invasive Colon Resection Better Than Traditional Approaches?

Early Discharge Programme on Hospital-at-Home Evaluation for Patients with Immediate Postoperative Course after Laparoscopic Colorectal Surgery

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